I, ____ son of ____ aged about __ years resident of ____, do hereby solemnly affirm and declare as under:-
1- That I have never been convicted by any court in ___ under the ____, and the rules ____ framed thereunder.
2- That I am ____ of ____.
3- That I hereby undertake that the premises in which I have applied for grant of licence is not meant for exclusive residential purpose/declared residential any act of rule of the Government.
4- That I also undertake that whole of the premises is situated an authorized area this building is not built in control version of any act of rule. If the above statement mine is found to be false any time in the future during the pendency of my licence may be cancelled without any notice.
I, the above named do hereby solemnly affirm and declare that whatever is stated above is true and correct to the best of my knowledge and belief and nothing has been concealed therein.
Verified at ____ on ____